CORRESPONDENCE
District Mean ivermectin coverage
1997 1998
Adjumani 79% 98%
Gulu Nil 96%
Kabale 89% 96%
Kisoro 82% 83%
Mbale 91% 96%
Nebbi 77% 85%
Rukungiri 96% 98%
Overall mean 7343% 9314%
Mean ivermectin coverage in percentage
of eligible population in the communities
by districts of Uganda (199799)
group is involved, then each should be
represented by an equal number. The
group attending the PEM should also
include about the same numbers of men
and women. PEMs require a trained
moderator, who is a good animator, and
three or four people with a good grasp of
the local language and culture to record
the proceedings. Proceedings should
also be tape-recorded and, whenever
possible, they should be enriched with
video shows and educational posters.
Advance information on the subject that
will be discussed should be given, and
the community members themselves
should be allowed to fix the day and
time of the PEM. Our implementation
of PEMs seems to have facilitated the
identification of pertinent concerns
within the communities, thus
contributing to improved ivermectin
coverage rates over the years in our
on-going community-directed pro-
grammes to control ochocerciasis
(table).
*Moses Katabarwa, Peace Habomugisha,
Frank Richards Jr
Carter Center, Global 2000 River Blindness
Program, PO Box 12027, Kampala, Uganda
(e-mail: rvbprg@starcom.co.ug)
1 Dignan BM, Carr PA. Program planning for
health education and promotion. 2nd edn.
Pennsylvania: Lea & Febiger, 1992.
Charles Bonnet syndrome
and dementia
SirIn 1760 the Swiss philosopher
Charles Bonnet described vivid,
complex visual hallucinations in his
otherwise psychologically normal
grandfather. This phenomenon, later
known as the Charles Bonnet
syndrome (CBS), has been repeatedly
observed in elderly ophthalmic
patients.1 Teunisse and colleagues2
showed 12% prevalence of CBS in a
group of 505 visually handicapped
adults. However, only a minority of the
visually handicapped experience visual
hallucinations and CBS has been
found in people with intact vision as
well.1 This finding suggests that while
2168
For personal use only. Not to be reproduced without permission of The Lancet.
visual impairment is probably an
1999
important aetiological factor, it is
unlikely to be the only one.
100%
100%
Dementia with Lewy Body (DLB),
93% possibly the most common cause of
88% dementia after Alzheimers disease
99% (AD), is characterised by fluctuating
96%
100%
cognitive decline, visual hallucinations,
and Parkinsonism.3 In a study of DLB,
9660%
Ballard and colleagues4 reported that
72% of 98 living patients and 65% of
80 patients who had neuropathological
necropsies experienced visual
hallucinations. This was significantly
higher than that of AD patients (16%
of 92 living patients and 25% of 40
necropsy patients).4 Moreover,
hallucinations were more common
early in the course of DLB than in
AD.5
Taken together, we should be aware
that some patients with DLB can be
diagnosed with CBS (particularly in
the early stages). Well-known
diagnostic criteria for CBS are:
presence of formed and complex,
persistent or repetitive visual
hallucinations; full or partial retention
of insight; absence of delusions; and
absence of hallucinations in other
sensory modalities.1,2 Accordingly, if a
patient with DLB has complex visual
hallucinations with insight in the
absence of other delusions or
hallucinations, on the basis of cross-
sectional observation, the symptoms
would be diagnosed as CBS.
For example, Aarsland and
colleagues3 reported the case of a
woman aged 71 years who had
experienced visual hallucinations,
suspiciousness, mild cognitive
impairment, repeated falls, and
syncope for 2 years. Thereafter, she
was admitted to hospital because of a
hip fracture. At this time no psychiatric
symptoms were recorded other than
visual hallucinations and mild-to-
moderate Parkinsonism. A Mini-
Mental State Examination score of 23
indicated mild cognitive impairment.
These symptoms were consistent with
DLB. After treatment with donepezil,
her cognitive function and visual
hallucinations improved gradually.
The visual hallucinations shifted from
hallucinations without insight to those
with insight, and to a complete
absence of hallucination during
donepezil treatment. These findings
suggests: hallucinations with insight
and those without insight may be
contained within the continuous
spectrum of hallucinations; and visual
hallucinations consistent with CBS
may occur in the early stages of DLB.
At least a part of the aetiology and
pathology of CBS may be associated
with DLB. If elderly people with
complex visual hallucinations with
insight are diagnosed as suffering from
CBS, they may be much relieved when
it is explained to them that such
hallucinations occur in psychologically
normal people. Nonetheless, in view of
the possible association between CBS
and DLB, we suggest that clinicians
follow such patients up, just in case.
Only careful longitudinal observation
can confirm the presence of DLB in
individual patients with CBS.
*Takeshi Terao, Simon Collinson
Neurosciences Building, Department of
Psychiatry, University of Oxford, Warneford
Hospital, Oxford OX3 7JK, UK
1 Teunisse RJ, Cruysberg JR,
Hoefnagels WH, Kuin Y, Verbeek AL,
Zitman FG. Social and psychological
characteristics of elderly visually
handicapped patients with the Charles
Bonnet Syndrome. Compr Psychiatry 1999;
40: 31519.
2 Teunisse RJ, Cruysberg JR, Hoefnagels
WH, Verbeek AL, Zitman FG. Visual
hallucinations in psychologically normal
people: Charles Bonnets syndrome. Lancet
1996; 347: 79497.
3 Aarsland D, Bonnick K, Karlsen K.
Donepezil for dementia with Lewy bodies:
a case study. Int J Geriatr Psychiatry 1999;
14: 6972.
4 Ballard C, Holmes C, McKeith I, et al.
Psychiatric morbidity in dementia with
Lewy bodies: a prospective clinical and
neuropathological comparative study with
Alzheimers disease. Am J Psychiatry 1999;
156: 103945.
5 Luis CA, Barker WW, Gajaraj K, et al.
Sensitivity and specificity of three clinical
criteria for dementia with Lewy bodies in an
autopsy-verified sample. Int J Geriatr
Psychiatry 1999; 14: 52633
Reducing withdrawal bleeds
SirI agree that contraceptive pill-
takers should be given the option to
eliminate their monthly withdrawal
bleeds. However, the essay by Sarah
Thomas and Charlotte Ellertson
(March 11, p 922)1 overlooks the
important point that if a woman takes a
combined oral contraceptive (COC) in
the normal 21/7 way she uses only 13
packets a year, whereas if she takes it
continuously she will require 17 packets.
This increases the annual hormone load
by 30% and runs counter to the medical
maxim of using the lowest dose for any
desired effect.
Demacker showed that serum lipid
changes measured after 21 days of pill-
taking returned towards normal by the
end of 7 pill-free days.2 Virtually all the
epidemiology documenting the amazing
safety record of the COC relates to its
use with 7 day breaks (and, therefore,
withdrawal bleeds). Although metabolic
changes are but surrogates for health
risks, it seems a reasonable hypothesis
that one safety factor might be the trend
THE LANCET Vol 355 June 17, 2000